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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 456-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance wiih San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin i Local Health District. 1 Job Address ��S� �� a ! 0,4vCity Lot Size PM i Owner's Name A 0-5T/H H OZ/17 C-5 Address je'9"v?S!n' Phone yam / Cbn 'ttactor -yell Address X47 4✓� License No, Phone TYPE OF,•WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑- -.• — - SYSTEM REPAIR -❑..�-�.� OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL — OTHER WELL PITS/SUMPS r^�1 ' V ' I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ` ❑ Domestic/Private ❑ Gravel Pack # ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation _.-Approx. Depth l I Eastern Surface Seal Installed by II Repair Work Done ❑ Type of Pump H.P. State Work Done _, y Well Destruction ❑ Well Diameter Sealing Material Itop 501 T Depth Filler Material lBelow-50') TYPE OF SEPTIC WORKc_NEW INSTALLATION yY REPAIR/ADDITION i-1--DESTRUCTION I I.INo-septic system permitted it public sewer is available within 200 feet.) + Installation will serve: Residence ` Commercial_ Other Number of living units: Number of bedrooms Charaof soil to a depth of 3 feet -riI a< <+pA� W cter at i table depth ��•�p .,_ SEPTIC TANK - @ Type/Mfg Capacity`f b� No. Compartments PKG. TREATMENT PLT. ❑ _ Method of Disposal Distance to nearest: Well b Foundation' Property Line 14M s �,�z LEACHING LINE �} No. & Length of lines g0� ,Total length/size �4 FILTER BED ❑ Distance to nearest: Well bf Foundations % Property Line /OO r SEEPAGE PITS 11 Depth 1.01 Size yz�' /E' _ Number t :SUMPS X Distance to nearest: Well /.7O Foundation Property Line 1100 DISPOSAL PONDS ❑ + ii I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county otdi&&tces, state laws, and I rules and regulations of the San Joaquin Local Health District. t 111 Home owner or licensed agent's signature certifies the following: "I certify that in the performance of IQIork for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of Califprn a 11. Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,_l shall employ persons subject to workman's compensa- tion laws of California." - t The applicant must call for all required inspections. Complete drawing on reverse side. a i Signed X _. Title: Date: t OR DEPARTMENT USE ONLY Application Accepted by Date '` Area / Pit or Grout Inspection by Qata f Final Inspection by t Date Additional Comments: � � ' ❑ Stk 466-6781 © Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies-to: Environmental health-Permit/Services 1601-E.-Hazelton-Ave., P.O.-Bdx'2009, Stk., CA 95201 FEEINFO AMOUNT DUE.» - .AMOUNT REMITTED=+ » ASW W-BY °' DATE PERMIT'NO. + EH 1324 IREV.I/x 51 EH 14-tai'